Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part IV

The Doubting Disease
Jerome Groopman, The New Yorker, April 10, 2000

On a snowy Sunday in winter, I attended a conference in Cambridge, Massachusetts. The participants included a wide variety of scientists: molecular biologists, organic chemists, computer programmers, virologists, clinical researchers, and statisticians. Afterward, a small group of us went to dinner at a local restaurant. During the meal, the conversation turned to schooling.
    "I transferred my eight-year-old out of public school last year," a chemist told the group. "The teacher wouldn't accommodate him. My kid is like me. When he has a problem to solve, he attacks it until it's done perfectly. He completely blocks out the world and won't let go. The teacher insisted that he couldn't spend more than the allotted time on a task. When my son wouldn't stop, the teacher concluded that he had a behavior disorder."
    This anecdote provoked a startlingly sympathetic response around the table: most of us, it turned out, identified with the chemist's son. A biologist known for deciphering, atom by atom, the three dimensional structure of complex proteins declared, "I bet I qualify for what psychiatrists call obsessive-compulsive disorder. When I'm reviewing lab data, and especially when I'm ready to send out a scientific paper, I keep thinking something is wrong. I become intensely anxious. I'll stay up all night reworking every graph and equation. I'm unable to get the thought out of my head that there's a mistake. Then I find myself checking other kinds of things. I'll go blocks away from the house and turn back to make sure the doors are locked, even though I know they are." He turned to the chemist. "I'm not sure what would have happened if I had had your son's teacher."
    What did it mean, I wondered as I left the restaurant, that a group of prominent scientists showed at least some traits associated with a clinical disorder during periods of high anxiety? More and more American children are being diagnosed and medicated every year, and at younger and younger ages. If my colleagues and I were in school now, would we be considered abnormal?
    Current estimates hold that more than two per cent of the United States population--nearly seven million people have or have had obsessive-compulsive disorder (O.C.D.). The American Psychiatric Association classifies all known mental disorders in its Diagnostic and Statistical Manual, or D.S.M. Obsessive-compulsive disorder, which usually manifests itself in adolescence, is characterized by recurrent, time-consuming obsessions or compulsions that are severe enough to cause marked distress or significant impairment. Furthermore, the person recognizes that his obsessions or compulsions are excessive or unreasonable. "Obsessions" are defined in the D. S.M. as persistent thoughts, impulses, or images that are experienced as intrusive, anxiety-producing and inappropriate.
    A person with such obsessions usually tries to ignore them, or to defuse them with some other thoughts or actions: this attempt defines a compulsion. You're obsessed with the thought that you didn't turn off the stove; you compulsively check to make sure it's off (The French call O.C.D. "the doubting disease.") Other well-recognized compulsions are hand-washing, counting, or repeating special words. In its extreme form, people afflicted with O.C.D. are virtual prisoners of their compulsions exhausted, ashamed, alienated from others. Certainly, nobody at the restaurant would have qualified for the diagnosis. Our obsessions tended to be temporary, and connected to a productive activity, like solving an equation. We may describe ourselves as "obsessive," but our obsessions don't control us.
    Although there is little information about the biological roots of the disorder--some have speculated that it can follow strep infections--recent studies indicate that people with O.C.D. have distinctive neurological circuitry. These differences are most pronounced in the limbic lobe, the caudate nucleus, and the orbital frontal cortex, the areas of the brain which participate in anxiety and automatic responses. Sophisticated brain scans show that when a potentially distressing scenario is confronted by a person without O.C.D., the brain activity in these areas barely registers on the screen; in a person with O.C.D., however, there is an intense and prolonged firing of neurons, and the scans light up like a Christmas tree. The Cambridge conference left me wondering whether scientists and other driven, detail-oriented professionals could also have distinctive neurological circuitry. Or are these mildly obsessive-compulsive people more likely to be attracted to these fields?
    The next day, I found myself taking another look at the familiar environment of my laboratory. In the lab--where many scientists spend ten to twelve hours each day, six to seven days a week, everything is tightly controlled. Tedious tasks demand absolute concentration, because a single error can wreck months of work. During our lab's weekly meeting, every detail of every experiment is intensely scrutinized and challenged as we search for those hidden, threatening mistakes. Is this the natural habitat of the obsessive-compulsive?
    Speaking with a score of fellow scientists throughout the week, I elicited anecdote after anecdote of mildly obsessive-compulsive behavior. One researcher said that when she approaches the lab to prepare for a particularly important experiment, she counts to herself and taps the wall as she walks down the corridor. Another "prefers" prime numbers, and counts to three or to seven before analyzing a sequence of DNA. A third told me that, during the month before her grant proposals are due, she repeatedly returns home to check the stove in her apartment, even though she knows that it is turned off.
    I also looked for survey studies on personality traits of scientists, or of children and adolescents who pursue careers in high technology. I searched for published articles in the National Library of Medicine, a repository of clinical literature; I checked listings of hundreds of popular books on Internet booksellers. Nothing specifically addressed the issue. I decided that it was time to seek professional help.
    "What is a disorder, anyway" the psychologist Jane Holmes Bernstein asked me rhetorically, in an animated English accent. Holmes Bernstein is the director of the neuropsychology program at Boston's Children's Hospital, and she is an expert at behavioral assessments of children. Like most scientists, she has a healthy skepticism toward her own field: "I decided early in the game that I needed to be hit with the full battery of neuropsychiatric tests that I give to kids--that it wasn't fair unless I experienced them." One day, when she was testing a child who had been referred to her for certain learning difficulties at school, she realized that he tested exactly as she herself had. "I asked myself, 'Why am I on my side of the desk? In my environment, I function at a high level, where it plays out adaptively."
    Holmes Bernstein argues that personality and behaviors can't be considered separately from the particular worlds in which people live; for that reason, she de-emphasizes labels and focuses instead on the relationship between behavior and environment. "Many psychiatrists and psychologists fit kids into diagnostic boxes," she asserted. "This thinking begins in medical school. There is distinctive, intrinsic organic pathology, the patient put into a box labeled 'diabetes' or 'H.I.V.' But those boxes are not built for behavior, because behavior is influenced so strongly by its interaction with environment."
    She suggested that O.C.D. is a response to excess arousal--arousal in this instance meaning a neurological response to environmental stimuli. "The O.C.D. neurological circuits in the limbic system are set higher for certain stimuli and can respond faster," Holmes Bernstein said. She pointed to recent studies at Indiana University which show that, under certain conditions, people with O.C.D. make associations between neutral as well as aversive stimuli more quickly than people without O.C.D.
    Holmes Bernstein believes that both this high state of arousal and the anxiety it produces may have evolutionary roots. In a prehistoric environment, those with the ability to focus and lock onto stimuli--particularly onto threatening elements in the environment--could have been better suited to escape the dangers of predators and treacherous terrain. But only to a point. "An adaptive mechanism can always become non-adaptive," Holmes Bernstein said.
    "This argument about the precise definition of O.C.D. is not just semantic, because it is the D.S.M. that dictates treatments," she went on. "Left to itself, the human animal accepts a wide range of behavior. O.C.D. becomes as much an issue of managing load in a high stimulus environment as it is a specific neurological disorder."
    After leaving Holmes Bernstein, I got in touch with Anthony Rao, a clinical psychologist who has a large community-based practice in child and adolescent psychology in the Boston area. Rao's specialty is behavioral therapy, and he regularly sees children like the chemist's son, who are brought by their parents or referred by teachers. He feels that he is constantly battling against misguided attempts to diagnose children and provide generic remedies. "There is too much pathologizing of people's behaviors," he said. "In the educational system, it's one size fits all. Teachers run to labels, like A.D.D."--attention-deficit disorder--"or O.C.D., and even tell parents their children need to start taking medication." Even among preschoolers, as a recent Journal of the American Medical Association study showed, there has been a sharp rise in the use of psychiatric medications, not only for A.D.D. but also for putative anxiety and depression.
    What drives all this, Rao believes, is the free-floating anxiety that parents--often successful members of the middle and upper class--foist on their children. In the instability of today's global economy, they fear that any deviation from the norm may cripple their child's future. He also believes that the currently fashionable psychiatric model--the idea that the problem is "a chemical disease of the brain--is overly simplistic and even dangerous. These days, psychiatrists primarily treat O.C.D. with selective serotonin re-uptake inhibitors, like Prozac and Luvox, which alleviate not only its symptoms but also the anxiety and depression that often accompany it. But Rao pointed out that no one knows precisely what the long-term effects of these drugs on children will be "especially when they are given daily for years." This approach, he contends, is treating the brain as if it were a bad kidney, when it's a far more complex organ, one which modifies itself continually.

The above text covers the first two pages of this four page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.


My Experience of Analysis with Fairbairn and Winnicott
(How Complete a Result Does Psycho-Analytic Therapy Achieve?)

Harry Guntrip (1975)

It does not seem to me useful to attempt a purely theoretical answer to the question forming the sub-title. Theory does not seem to me to be the major concern. It is a useful servant but a bad master, liable to produce orthodox defenders of every variety of the faith. We ought always to sit light to theory and be on the look-out for ways of improving it in the light of therapeutic practice. It is therapeutic practice that is the real heart of the matter. In the last resort good therapists are born not trained, and they make the best use of training. Maybe the question ' How complete a result can psychoanalytic therapy produce?' raises the question ' How complete a result did our own training analysis produce?' Analysts are advised to be open to post-analytic improvements, so presumably we do not expect 'an analysis' to do a 'total' once for all job. We must know about post-analytic developments if we are to assess the actual results of the primary analysis. We cannot deal with this question purely on the basis of our patients' records. They must be incomplete for the primary analysis and non-existent afterwards. As this question had unexpected and urgent relevance in my case, I was compelled to grapple with it; so I shall risk offering an account of my own analysis with Fairbairn and Winnicott, and its after-effects: especially as this is the only way I can present a realistic picture of what I take to be the relationship between the respective contributions of these two outstanding analysts, and what I owe to them.|
    The question ' How complete a result is possible?' had compelling importance for me because it is bound up with an unusual factor; a total amnesia for a severe trauma at the age of three and a half years, over the death of a younger brother. Two analyses failed to break through that amnesia, but it was resolved unexpectedly after they had ended, certainly only because of what they had achieved in 'softening up' the major repression. I hope this may have both a theoretical and a human interest. The long quest for a solution to that problem has been too introverted an interest to be wholly welcomed, but I had no option, could not ignore it. and so turned it into a vocation through which I might help others. Both Fairbairn and Winnicott thought that but for that trauma, I might not have become a psychotherapist. Fairbairn once said: 'I can't think what could motivate any of us to become psychotherapists, if we hadn't got problems of our own'. He was no super-optimist and once said to me: 'The basic pattern of personality once fixed in early childhood, can't be altered. Emotion can be drained out of the old patterns by new experience, but water can always flow again in the old dried up water courses'. You cannot give anyone a different history. On another occasion he said: 'You can go on analyzing for ever and get nowhere. It's the personal relation that is therapeutic. Science has no values except scientific values, the schizoid values of the investigator who stands outside of life and watches. It is purely instrumental, useful for a time but then you have to get back to living.' That was his view of the 'mirror analyst', a non-relating observer simply interpreting. Thus he held that psychoanalytic interpretation is not therapeutic per se, but only as it expresses a personal relationship of genuine understanding. My own view is that science is not necessarily schizoid, but is really practically motivated, and often becomes schizoid because it offers such an obvious retreat for schizoid intellectuals. There is no place for this in psychotherapy of any kind.
    I already held the view that psychoanalytic therapy is not a purely theoretical but a truly understanding personal relationship, and had published it in my first book before I had heard of Fairbairn; after reading his papers in 1949, I went to him because we stood philosophically on the same ground and no actual intellectual disagreements would interfere with the analysis. But the capacity for forming a relationship does not depend solely on our theory. Not everyone has the same facility for forming personal relationships, and we can all form a relationship more easily with some people than with others. The unpredictable factor of 'natural fit' enters in. Thus, in spite of his conviction Fairbairn did not have the same capacity for natural, spontaneous 'personal relating' that Winnicott had. With me he was more of a 'technical interpreter' than he thought he was, or than I expected: but that needs qualification. I went to him in the 1950s when he was past the peak of his creative powers of the 1940s, and his health was slowly failing. He told me that in the 1930s and 1940s he had treated a number of schizophrenic and regressed patients with success. That lay behind his 'theoretical revision' in the 1940s. He felt he had made a mistake in publishing his theory before the clinical evidence. From 1927 to 1935 he was psychiatrist at The University Psychological Clinic for Children, and did a lot of work for the N.S.P.C.C. One cannot be impersonal with children. He asked one child whose mother thrashed her cruelly: 'Would you like me to find you a new kind Mummy?' She said: 'No. I want my own Mummy', showing the intensity of the libidinal tie to the bad object. The devil you know is better than the devil you do not, and better than no devil at all. Out of such experience with psychotic, regressed and child patients, his theoretical revision grew, based on the quality of parent-child relations, rather than the stages of biological growth, a 'personality-theory' not an impersonal 'energy-control theory'. He summed it up in saying that 'the cause of trouble is that parents somehow fail to get it across to the child that he is loved for his own sake, as a person in his own right'. By the 1950s when I was with him, he wisely declined to take the strains of severely regressing patients. To my surprise I found him gradually falling back on the 'classical analyst' with an 'interpretative technique', when I felt I needed to regress to the level of that severe infancy trauma.
    Stephen Morse (1972), in his study of 'structure' in the writings of Winnicott and Balint, concluded that they discovered new data but did not develop structural theory in a way that could explain them; which, however, he felt could be done by what he called the 'Fairbairn-Guntrip metaphor'. Having had the benefit of analysis with both these outstanding analysts, I feel the position is somewhat more complex than that. The relation between Fairbairn and Winnicott is both theoretically important and very intriguing. Superficially they were quite unlike each other in type of mind and method of working, which prevented their knowing how basically close they were in the end. Both had deep roots in classic Freudian theory and therapy, and both outgrew it in their own different ways. Fairbairn saw that intellectually more clearly than Winnicott. Yet in the 1950s Fairbairn was more orthodox in clinical practice than Winnicott. I had just over 1,000 sessions with Fairbairn in the 1950s and just over 150 with Winnicott in the 1960s. For my own benefit I kept detailed records of every session with both of them, and all their correspondence. Winnicott said, 'I've never had anyone who could tell me so exactly what I said last time.' Morse's article suggested a restudy of those records last year, and I was intrigued to find the light they cast on why my two analyses failed to resolve my amnesia for that trauma at three and a half years, and yet each in different ways prepared for its resolution as a post-analytic development. I had to ask afresh, ' What is the analytic therapeutic process? '
    In general I found Fairbairn becoming more orthodox in practice than in theory while Winnicott was more revolutionary in practice than in theory. They were complementary opposites. Sutherland in his obituary notice (I 965) wrote:

Fairbairn had a slightly formal air about him--notably aristocratic, but in talking to him I found he was not at all formal or remote. Art and religion were for him profound expressions of man's needs, for which he felt a deep respect, but his interests revealed his rather unusual conservatism.

    I found him formal in sessions, the intellectually precise interpreting analyst, but after sessions we discussed theory and he would unbend, and I found the human Fairbairn as we talked face to face. Realistically, he was my understanding good father after sessions, and in sessions in the transference he was my dominating bad mother imposing exact interpretations. After his experimental creative 1940s, I feel his conservatism slowly pushed through into his work in the 1950s. The shock of his wife's sudden death in 1952 created obvious domestic problems. Early in the 1950s he had the first attack of viral influenza, and these became more virulent as the decade advanced. For two years after his wife's death he worked hard on his fine paper, 'Observations on the nature of hysterical states ' (Fairbairn, 1954) which finalized his original thinking. He clarified his views on 'psychoanalysis and science' in two papers (Fairbairn, 1952b, 1955). But there was a subtle change in his next paper, 'Considerations arising out of the Schreber case' (Fairbairn, 1956). Here he fell back from his 'ego and object relations' psychology, explaining everything as due to 'primal scene' libidinal excitations and fears. Finally, in his last paper, 'On the nature and aims of psycho-analytical treatment' (Fairbairn, 1958) his entire emphasis was on the 'internal closed system' of broadly oedipal analysis, not in terms of instincts, but of internalized libidinized and anti-libidinized bad-object relations. I went to him to break through the amnesia for that trauma of my brother's death, to whatever lay behind it in the infancy period. There, I felt, lay the cause of my vague background experiences of schizoid isolation and unreality, and I knew that they had to do with my earliest relations with my mother, though only because of information she had given me.
    After brother Percy's death I entered on four years of active battle with mother to force her 'to relate', and then gave it up and grew away from her. I will call that, for convenience, the oedipal internalized bad-object relations period: it filled my dreams, but repeatedly sudden, clear schizoid experiences would erupt into this, and Fairbairn steadily interpreted them as 'withdrawal' in the sense of 'escapes' from internalized bad-object relations. He repeatedly brought me back to oedipal three-person libidinal and anti-libidinal conflicts in my 'inner world', Kleinian ' object splits ' and Fairbairnian 'ego splits ' in the sense of oedipal libidinal excitations. In 1956 I wrote to ask him to say exactly what he thought about the Oedipus complex, and he replied: 'The Oedipus complex is central for therapy but not for theory.' I replied that I could not accept that: for me theory was the theory of therapy, and what was true for one must be true for both. I developed a double resistance to him consciously, partly feeling he was my bad mother forcing her views on me and partly openly disagreeing. with him on genuine grounds. I began to insist that my real problem was not the bad relationships of the post-Percy period, but mother's basic 'failure to relate at all' right from the start. I said that I felt oedipal analysis kept me marking time on the same spot, making me use bad relations as better than none at all, keeping them operative in my inner world as a defense against the deeper schizoid problem. He saw that as a defensive character trait of 'withdrawness' (Fairbairn, 1952a, chap. 1). I felt it as a problem in its own right, not just a defense against his closed-system ' internal world of bad-object relations'.
    But my oedipal analysis with Fairbairn was not a waste of time. Defenses have to be analyzed and it brought home to me that I had actually repressed the trauma of Percy's death and all that lay behind it, by building over it a complex experience of sustained struggle in bad-object relations with mother, which in turn I had also to repress. It was the basis of my spate of dreams, and intermittent production of conversion symptoms. Fairbairn for long insisted that it was the real core of my psychopathology. He was certainly wrong, but it did have to be radically analyzed to open the way to the deeper depths. That happened. Steadily regressive and negative schizoid phenomena thrust into the material I brought to him, and at last he began to accept in theory what he no longer had the health to cope with in practice. He generously accepted my concept of a 'regressed ego' split off from his 'libidinal ego' and giving up as hopeless the struggle to get a response from mother. When I published that idea, Winnicott wrote to ask: 'Is your Regressed Ego withdrawn or repressed?' I replied: 'Both. First withdrawn and then kept repressed'. Fairbairn wrote to say:

This is your own idea, not mine, original, and it explains what I have never been able to account for in my theory, Regression. Your emphasis on ego-weakness yields better therapeutic results than interpretation in terms of libidinal and anti-libidinal tensions.

    When in 1960 I wrote 'Ego-weakness, the hard core of the problem of psychotherapy,' he wrote to say: 'If I could write now, that is what I would write about'. I knew my theory was broadly right for it conceptualized what I could not yet get analyzed. With I think great courage, he accepted that.
    I shall complete my account of Fairbairn as analyst and man by illustrating the difference in 'human type' between him and Winnicott, a factor that plays a big part in therapy. The set-up of the consulting room itself creates an atmosphere which has meaning. Fairbairn lived in the country and saw patients in the old Fairbairn family house in Edinburgh. I entered a large drawing room as waiting room, furnished with beautiful valuable antiques, and proceeded to the study as consulting room, also large with a big antique bookcase filling most of one wall. Fairbairn sat behind a large flat-topped desk, I used to think 'in state' in a high-backed plush-covered armchair. The patient's couch had its head to the front of the desk. At times I thought he could reach over the desk and hit me on the head. It struck me as odd for an analyst who did not believe in the 'mirror-analyst' theory. Not for a long time did I realize that I had 'chosen' that couch position, and there was a small settee at the side of his desk at which I could sit if I wished, and ultimately I did. That this imposing situation at once had an unconscious transference meaning for me became clear in a dream in the first month. I must explain that my father had been a Methodist Local Preacher of outstanding eloquence as a public speaker, and from 1885 built up and led a Mission Hall which grew into a Church which still exists. In all my years of dreaming he never appeared as other than a supportive figure vis-a-vis mother, and in actual fact she never lost her temper in his presence. I wanted Fairbairn in transference as the protective father, helping me to stand up to my aggressive mother, but unconsciously I felt otherwise, for I dreamed:

I was in father's Mission Hall. Fairbairn was on the platform but he had mother's hard face. I lay passive on a couch on the floor of the Hall, with the couch head to the front of the platform. He came down and said: 'Do you know the door is open?' I said: 'I didn't leave it open', and was pleased I had stood up to him. He went back to the platform.

It was a thinly disguised version of his consulting room set-up, and showed that I wanted him to be my supportive father, but that wish was overpowered by a clear negative transference from my severe dominating mother. That remained by and large Fairbairn's transference role 'in sessions'. He interpreted it as the 'one up and the other down' bad parent-child 'see-saw' relation. It can only be altered by turning the tables. I found that very illuminating, containing all the ingredients of unmet needs, smothered rage, inhibited spontaneity. It was the dominant transference relationship in sessions. After sessions Fairbairn could unbend in our theory and therapy discussion, the good human father.
    This negative transference in sessions was, I feel, fostered by his very intellectually precise interpretations. Once he interpreted: 'Something forecloses on the active process in the course of its development'. I would have said: 'Your mother squashed your naturally active self '. But he accurately analyzed my emotional struggle to force mother to mother me after Percy died, and showed how I had internalized it. That had to be done first, but he held it to be the central oedipal problem, and could not accept till it was too late, that this masked a far deeper and more serious problem. Later Winnicott twice remarked: 'You show no signs of ever having had an Oedipus complex'. My family pattern was not oedipal. It was always the same in dreams and is shown by the most striking one of them.

I was being besieged and was sitting in a room discussing it with father. It was mother who was besieging me and I said to him: 'You know I'll never give in to her. It doesn't matter what happens. I'll never surrender'. He said, 'Yes. I know that. I'll go and tell her' and he went and said to her, 'You'd better give it up. You'll never make him submit', and she did give up.

Fairbairn's persistence in oedipal interpretations I could not accept as final, cast him in the role of the dominating mother. It came to our ears that Winnicott and Hoffer thought my adherence to his theory was due to its not allowing him to analyze my aggression in the transference. But they didn't see me knock over his pedestal ashtray, and kick his glass door-stopper, 'accidentally' of course, and we know what that means in sessions, as he was not slow to point out. They did not see me once strew some of his books out of that huge bookcase over the floor, symbolic of 'tearing a response out of mother', and then putting them back tidily to make reparation a la Melanie Klein. But after sessions we could discuss and I could find the natural warm-hearted human being behind the exact interpreting analyst.
    I can best make this clear by comparison with Winnicott. His consulting room was simple, restful in colors and furniture, unostentatious, carefully planned, so Mrs. Winnicott told me, by both of them, to make the patient feel at case. I would knock and walk in, and presently Winnicott would stroll in with a cup of tea in his hand and a cheery 'Hallo', and sit on a small wooden chair by the couch. I would sit on the couch sideways or lie down as I felt inclined, and change position freely according to how I felt or what I was saying. Always at the end, as I departed he held out his hand for a friendly handshake. As I was finally leaving Fairbairn after the last session, I suddenly realized that in all that long period we had never once shaken hands, and he was letting me leave without that friendly gesture. I put out my hand and at once he took it, and I suddenly saw a few tears trickle down his face. I saw the warm heart of this man with a fine mind and a shy nature. He invited my wife and me to tea whenever we visited her mother in Perthshire.
    To make the ending of my analysis with Fairbairn meaningful, I must give a brief sketch of my family history. My mother was an overburdened 'little mother' before she married, the eldest daughter of 11 children and saw four siblings die. Her mother was a featherbrained beauty queen, who left my mother to manage everything even as a schoolgirl. She ran away from home at the age of twelve because she was so unhappy, but was brought back. Her best characteristic was her strong sense of duty and responsibility to her widowed mother and three younger siblings, which impressed my father when they all joined his Mission Hall. They married in 1898 but he did not know that she had had her fill of mothering babies and did not want any more. In my teens she occasionally became confidential and told me the salient facts of family history, including that she breast fed me because she believed it would prevent another pregnancy; she refused to breast feed Percy and he died, after which she refused further intimacy. My father was the youngest son of a High-Church and high Tory family, the politically left-wing and religiously nonconformist rebel; and anti-imperialist who nearly lost his position in the City by refusing to sign his firm's pro-Boer War petition. That passing anxiety gave my mother the chance to wean me suddenly and start a business of her own. We moved when I was one year old. She chose a bad site and lost money steadily for seven years, though everything was more than retrieved by the next move. That first seven years of my life, six of them at the first shop, was the grossly disturbed period for me. I was left to the care of an invalid aunt who lived with us. Percy was born when I was two years old and died when I was three and a half. Mother told me father said he would have lived if she had breast fed him, and she got angry. It was a disturbed time. In her old age, living in our home, she would say some revealing things. 'I ought never to have married and had children. Nature did not make me to be a wife and mother, but a business woman', and 'I don't think I ever understood children. I could never be bothered with them'.
    She told me that at three and a half years I walked into a room and saw Percy lying naked and dead on her lap. I rushed up and grabbed him and said: 'Don't let him go. You'll never get him back! 'She sent me out of the room and I fell mysteriously ill and was thought to be dying. Her doctor said: 'He's dying of grief for his brother. If your mother won't can't save him, I can't, so she took me to a maternal aunt who had a family, and there I recovered. Both Fairbairn and Winnicott thought I would have died if she had not sent me away from herself. All memory of that was totally repressed. The amnesia held through all the rest of my life and two analyses, till I was 70, three years ago. But it remained alive in me, to be triggered off unrecognized by widely spaced analogous events. At the age of 26, at the University, I formed a good friendship with a fellow student who was a brother figure to me. When he left and I went home on vacation to mother, I fell ill of a mysterious exhaustion illness which disappeared immediately I left home and returned to College. I had no idea that it was equivalent to that aunt's family. In 1938, aged 37, 1 became minister of a highly organized Church in Leeds, with a Sunday afternoon meeting of 1,000 men, an evening congregation of 800, and well organized educational, social and recreational activities. It was too large for one minister and I had a colleague who became another Percy-substitute. He left as war clouds loomed up. Again I suddenly fell ill of the same mysterious exhaustion illness. It was put down to overwork, but by then I was psychoanalytically knowledgeable, had studied classical theory under Flugel, knew the stock literature, had an uncompleted M.A. thesis under supervision of Professor John Macmurray, seeking to translate Freud's psychobiology, or rather clinical data, into terms of 'personal relations' philosophy, and had studied my own dreams for two years. So I was alerted when this illness brought a big dream.

I went down into a tomb and saw a man buried alive. He tried to get out but I threatened him with illness, locked him in and got away quick.

Next morning I was better. For the first time I recognized the re-eruption of my illness after Percy's death, and saw that I lived permanently over the top of its repression. I knew then I could not rest till that problem was solved.
    I was drawn into war-time emergency psychotherapy by the Leeds Professor of Medicine, appointed to a lectureship in the Medical School, and went on studying my own dreams. I recently re-read the record and found I had only made forced text-bookish oedipal interpretations. Of more importance was that three dominant types of dream stood out: (1) a savage woman attacking me, (2) a quiet, firm, friendly father figure supporting me, and (3) a mysterious death-threat dream, the clearest example based on the memory of mother taking me at the age of six into the bedroom of my invalid aunt, thought to be dying of rheumatic fever, lying white and silent. In one dream:

I was working downstairs at my desk and suddenly an invisible band of ectoplasm tying me to a dying invalid upstairs, was pulling me steadily out of the room. I knew I would be absorbed into her. I fought and suddenly the band snapped and I knew I was free.

I knew enough to guess that the memory of my dying aunt was a screen memory for the repressed dead Percy, which still exercised on me an unconscious pull out of life into collapse and apparent dying. I knew that somehow, sometime I must get an analysis. In 1946 Professor Dicks appointed me as the first staff member of the new Department of Psychiatry, and said that with my views I must read Fairbairn. I did so and at the end of 1949 I sought analysis with him.
    For the first few years, his broadly oedipal analysis of my 'internal bad-object relations' world did correspond to an actual period of my childhood. After Percy's death and my return home, from the age of three and a half to five, I fought to coerce mother into mothering me by repeated petty psychosomatic ills, tummyaches, heat spots, loss of appetite, constipation and dramatic, sudden high temperatures, for which she would make me a tent-bed on the kitchen couch and be in and out from the shop to see me. She told me the doctor said: 'I'll never come to that child again. He frightens the life out of me with these sudden high temperatures and next morning he's perfectly well'. But it was all to no purpose. Around five years I changed tactics. A new bigger school gave me more independence, and mother said: 'You began not to do what I told you'. She would fly into violent rages and beat me, from about the time I was five to the age of seven. When canes got broken I was sent to buy a new one. At the age of seven I went to a still larger school and steadily developed a life of my own outside the home. We moved when I was eight to another shop where mother's business was an outstanding success. She became less depressed, gave me all the money I needed for hobbies and outdoor activities, scouting, sport, and gradually I forgot not quite all the memories of the first seven bad years. It was all the fears, rages, guilts, psychosomatic transient symptoms, disturbed dreams, venting the conflicts of those years from three and a half to seven, that Fairbairn's analysis dealt with. In mother's old age she said: 'When your father and Aunt Mary died and I was alone, I tried keeping a dog but I had to give it up. I couldn't stop beating it'. That's what happened to me. No wonder I had an inner world of internalized libidinally excited bad-object relations, and I owe much to Fairbairn's radical analysis of it.
    But after the first three or four years, I became convinced that this was keeping me marking time in a sadomasochistic inner world of bad object relations with mother, as a defense against quite different problems of the period before Percy's death. This deeper material kept pushing through. The crunch came in December 1957 when my old friend whose departure from College caused the first eruption of that Percy illness in 1927, suddenly died. For the third time exhaustion seized me. I kept going to work and traveling to Edinburgh for analysis, feeling I would now get to the bottom of it. Then, just as I felt some progress was being made, Fairbairn fell ill with a serious viral influenza of which he nearly died, and was off work six months. I had to reinstate repression, but at once began to 'intellectualize' the problem I could not work through with him in person. It was not pure intellectualization by deliberate thinking. Spontaneous insights kept welling up at all sorts of times, and I jotted them down as they flowed with compelling intensity. Out of all that I wrote three papers; they became the basis of my book Schizoid Phenomena, Object Relations and The Self (I 968): 'Ego-weakness, the core of the problem of psychotherapy' written in 1960 (chapter 6), 'The schizoid problem, regression and the struggle to preserve an ego ' (chapter 2) written in 1961, and 'The manic-depressive problem in the light of the schizoid process' (chapter 5) written in 1962. In two years they took me right beyond Fairbairn's halting point. He generously accepted this as a valid and necessary extension of his theory.
    When he returned to work in 1959, 1 discussed my friend's death and Fairbairn's illness and he made a crucial interpretation: 'I think since my illness I am no longer your good father or bad mother, but your brother dying on you'. I suddenly saw the analytical situation in an extraordinary light, and wrote him a letter which I still have, but did not send. I knew it would put a bigger strain on him than he could stand in his precarious health. I suddenly saw that I could never solve my problem with an analyst. I wrote: 'I am in a dilemma. I have got to end my analysis to get a chance to finish it, but then I do not have you to help me with it.' Once Fairbairn had become my brother in transference, losing him either by ending analysis myself, or by staying with him till he died, would represent the death of Percy, and I would be left with a full scale eruption of that traumatic event, and no one to help me with it. Could Fairbairn have helped me with that in transference analysis? Not in his frail state of health and I phased out my analysis in that year. I have much cause to be grateful to him for staying with me, in his increasingly weak state of health, till I had reached that critical insight. The driving force behind my theory writing in 1959-1962 was the reactivation of the Percy-trauma, causing a compelling spate of spontaneous ideas. I could contain it and use it for constructive research, partly because I was giving Fairbairn up gradually, partly because he accepted the validity of my ideas, and partly because I had resolved to seek analysis with Winnicott before Fairbairn died.
    Fairbairn first introduced me to Winnicott in 1954 by asking him to send me a copy of his paper: 'Regression Within the Psycho-Analytical Set-Up' (in Winnicott, 1958). He sent it and, rather to my surprise, a letter saying: 'I do invite you to look into the matter of your relation to Freud, so that you may have your own relation and not Fairbairn's. He spoils his good work by wanting to knock down Freud'. We exchanged three long letters on each side. I stated that my relation to Freud had been settled years before I had heard of Fairbairn, when studying under Flugel at University College, London. I rejected Freud's psychobiology of instincts, but saw the great importance of his discoveries in psychopathology. Regarding that correspondence I now find I anticipated Morse's (1972) conclusion almost in his words, 18 years earlier: that Winnicott's 'true self 'has no place in Freud's theory. It could only be found in the id, but that is impossible because the id is only impersonal energy. In fact I felt that Winnicott had left Freud as far behind in therapy as Fairbairn had done in theory. In 1961 I sent him a copy of my book Personality Structure and Human Interaction (Guntrip, 1961) and he replied that he had already purchased a copy. I was reading his papers as they were published, as also was Fairbairn who described him as 'clinically brilliant'. By 1962 I had no doubt that he was the only other man that I could turn to for help. I was by then only free to visit London once a month for a couple of sessions, but the analysis I had had made it easier to profit by that. From 1962 to 1968 I had 150 sessions and their value was out of all proportion to their number. Winnicott said he was surprised that so much could be worked through in such widely spaced sessions, due I think in the first place to all the preliminary clearing that had been done by Fairbairn and to the fact that I could keep the analysis alive between visits; but most of all to Winnicott's profound intuitive insights into the very infancy period I so needed to get down to. He enabled me to reach extraordinarily clear evidence that my mother had almost certainly had an initial period of natural maternalism with me as her first baby, for perhaps a couple of months, before her personality problems robbed me of that 'good mother'. I had quite forgotten that letter I did not send to Fairbairn about the dilemma of not being able either to end analysis or go on with it, once my analyst became Percy in the transference. Ending it would be equivalent to Percy dying and I would have no one to help me with the aftermath. If I did not end it, I would be using my analyst to prevent the eruption of the trauma and so get no help with it, and risk his dying on me. My amnesia for that early trauma was not broken through with Winnicott either. Only recently have I realized that in fact, unwittingly, he altered the whole nature of the problem by enabling me to reach right back to an ultimate good mother, and to find her recreated in him in the transference. I discovered later that he had put me in a position to face what was a double trauma of both Percy's death and mother's failing me.
    As I re-read my records I am astonished at the rapidity with which he went to the heart of the matter. At the first session I mentioned the amnesia for the trauma of Percy's death, and felt I had had a radical analysis with Fairbairn of the 'internalized bad-object defenses' I had built up against that, but we had not got down to what I felt was my basic problem, not the actively bad-object mother of later childhood, but the earlier mother who failed to relate at all. Near the end of the session he said: 'I've nothing particular to say yet, but if I don't say something, you may begin to feel I'm not here. At the second session he said:

You know about me but I'm not a person to you yet. You may go away feeling alone and that I'm not real. You must have had an earlier illness before Percy was born, and felt mother left you to look after yourself. You accepted Percy as your infant self that needed looking after. When he died, you had nothing and collapsed.

That was a perfect object relations interpretation, but from Winnicott, not Fairbairn. Much later I said that I occasionally felt a 'static, unchanging, lifeless state somewhere deep in me, feeling I can't move'. Winnicott said:

If 100% of you felt like that, you probably couldn't move and someone would have to wake you. After Percy died, you collapsed bewildered, but managed to salvage enough of yourself to go on living, very energetically, and put the rest in a cocoon, repressed, unconscious.

I wish there were time to illustrate his penetrating insight in more detail, but I must give another example. I said that people often commented on my ceaseless activity and energy, and that in sessions I did not like gaps of silence and at times talked hard. Fairbairn interpreted that I was trying to take the analysis out of his hands and do his job; steal father's penis, oedipal rivalry. Winnicott threw a dramatic new fight on this talking hard. He said:

Your problem is that that illness of collapse was never resolved. You had to keep yourself alive in spite of it. You can't take your ongoing being for granted. You have to work hard to keep yourself in existence. You're afraid to stop acting, talking or keeping awake. You feel you might die in a gap like Percy, because if you stop acting, mother can't do anything. She couldn't save Percy or you. You're bound to fear I can't keep you alive, so you link up monthly sessions for me by your records. No gaps. You can't feel that you are a going concern to me, because mother couldn't save you. You know about 'being active' but not about 'just growing, just breathing' while you sleep, without your having to do anything about it.

I began to be able to allow for some silences, and once, feeling a bit anxious, I was relieved to hear Winnicott move. I said nothing, but with uncanny intuition he said:

You began to feel afraid I'd abandoned you. You feel silence is abandonment. The gap is not you forgetting mother, but mother forgetting you, and now you've relived it with me. You're finding an earlier trauma which you might never recover without the help of the Percy trauma repeating it. You have to remember mother abandoning you by transference on to me.

I can hardly convey the powerful impression it made on me to find Winnicott coming right into the emptiness of my 'object relations situation' in infancy with a non-relating mother.
    Right at the end of my analysis I had a sudden return of hard talking in session. This time he made a different and extraordinary statement. He said:

It's like you giving birth to a baby with my help. You gave me half an hour of concentrated talk, rich in content. I felt strained in listening and holding the situation for you. You had to know that I could stand your talking hard at me and my not being destroyed. I had to stand it while you were in labor being creative, not destructive, producing something rich in content. You are talking about 'object relating', 'using the object' and finding you don't destroy it. I couldn't have made that interpretation five years ago.

Later he gave his paper on 'The use of an object' (in Winnicott, 1971) in America and met, not surprisingly I think, with much criticism. Only an exceptional man could have reached that kind of insight. He became a good breast mother to my infant self in my deep unconscious, at the point where my actual mother had lost her maternalism and could not stand me as a live baby any more. It was not then apparent, as it later became to me, that he had transformed my whole understanding of the trauma of Percy's death, particularly when he added:

You too have a good breast. You've always been able to give more than take. I'm good for you but you're good for me. Doing your analysis is almost the most reassuring thing that happens to me. The chap before you makes me feel I'm no good at all. You don't have to be good for me. I don't need it and can cope without it, but in fact you are good for me.

Here at last I had a mother who could value her child, so that I could cope with what was to come. It hardly seems worth mentioning that the only point at which I felt I disagreed with Winnicott was when he talked occasionally about 'getting at your primitive sadism, the baby's ruthlessness and cruelty, your aggression', in a way that suggested not my angry fight to extract a response from my cold mother, but Freud's and Klein's 'instinct theory', the id, innate aggression. For I knew he rejected the 'death instinct ' and had moved far beyond Freud when I went to him. He once said to me: 'We differ from Freud. He was for curing symptoms. We are concerned with living persons, whole living and loving'. By 1967 he wrote, and gave me a copy of his paper, 'The location of cultural experience' (in Winnicott, 1971), in which he said: 'I see that I am in the territory of Fairbairn: "object-seeking" as opposed to "satisfaction seeking". I felt then that Winnicott and Fairbairn had joined forces to neutralize my earliest traumatic years.
    I must complete this account with the one thing I could not foresee. Winnicott becoming the good mother, freeing me to be alive and creative, transformed the significance of Percy's death in a way that was to enable me to resolve that trauma, and my dilemma about how to end my analysis. Winnicott, relating to me in my deep unconscious, enabled me to stand seeing that it was not just the loss of Percy, but being left alone with the mother who could not keep me alive, that caused my collapse into apparent dying. But thanks to his profound intuitive insight, I was not now alone with a non-relating mother. I last saw him in July 1969. In February 1970 I was told medically that I was seriously overworked, and if I did not retire ' Nature would make me'. I must have felt unconsciously that that was a threat that 'Mother Nature' would at last crush my active self. Every time I rested I found myself under a compulsion to go back to the past, in the form of rehearsing the details of my ministerial 'brother-figure's' leaving in 1938, and my reacting with an exhaustion illness. I soon saw that this was significant and it led on to an urge to write up my whole life-story, as if I had to find out all that had happened to me. By October I developed pneumonia and spent five weeks in hospital. The consultant said: 'Relax. You're too overactive'. I still did not realize that I was fighting against an unconscious compulsive regression. I had never linked the idea of 'retirement' with the deep fear of losing my battle with mother to keep my active self alive, in the end. After a slow winter recuperation, I heard in the New Year 1971 that Winnicott had a flu attack.
    Presently I inquired of Masud Khan how Winnicott was, and he replied that he was about again and liked to hear from his friends, so I dropped him a line. A little later the phone rang, and the familiar voice said: ' Hallo. Thanks for your letter ' and we chatted a bit. About two weeks later the phone rang again and his secretary told me he had passed away. That very night I had a startling dream. I saw my mother, black, immobilized, staring fixedly into space, totally ignoring me as I stood at one side staring at her and feeling myself frozen into immobility: the first time I had ever seen her in a dream like that. Before she had always been attacking me. My first thought was: 'I've lost Winnicott and am left alone with mother, sunk in depression, ignoring me. That's how I felt when Percy died '. I thought I must have taken the loss of Winnicott as a repetition of the Percy trauma. Only recently have I become quite clear that it was not that at all. I did not dream of mother like that when my college friend died or my ministerial colleague left. Then I felt ill, as after Percy's death. This time it was quite different. That dream started a compelling dream-sequence which went on night after night, taking me back in chronological order through every house I had lived in, in Leeds, Ipswich, College, the second Dulwich shop, and finally the first shop and house of the bad first seven years. Family figures, my wife, daughter, Aunt Mary, father and mother kept recurring; father always supportive, mother always hostile, but no sign of Percy. I was trying to stay in the post-Percy period of battles with mother. Then after some two months two dreams at last broke that amnesia for Percy's life and death. I was astonished to see myself in a dream clearly aged about three, recognizably me, holding a pram in which was my brother aged about a year old. I was strained, looking anxiously over to the left at mother, to see if she would take any notice of us. But she was staring fixedly into the distance, ignoring us, as in the first dream of that series. The next night the dream was even more startling.

I was standing with another man, the double of myself, both reaching out to get hold of a dead object. Suddenly the other man collapsed in a heap. Immediately the dream changed to a lighted room, where I saw Percy again. I knew it was him, sitting on the lap or a woman who had no face, arms or breasts. She was merely a lap to sit on, not a person. He looked deeply depressed, with the comers of his mouth turned down, and I was trying to make him smile.

I had recovered in that dream the memory of collapsing when I saw him as a dead object and reached out to grab him. But I had done more. I had actually gone back in both dreams to the earlier time before he died, to see the ' faceless ' depersonalized mother, and the black depressed mother, who totally failed to relate to both of us. Winnicott had said:' You accepted Percy as your infant self that needed looking after. When he died, you had nothing and collapsed. Why did I dream of 'collapsing' first, and then of going back to look after Percy? My feeling is that my collapse was my first reaction of terrified hopelessness at the shock of finding Percy dead on mother's lap, but in that aunt's family I quickly seized the chance of staying alive by finding others to live for.
    That dream series made me bring out and restudy all my analysis records, till I realized that, though Winnicott's death had reminded me of Percy's, the situation was entirely different. That process of compelling regression had not started with Winnicott's death, but with the threat of 'retirement' as if mother would undermine me at last. I did not dream of Winnicott's death, but of Percy's death and mother's total failure to relate to us. What better dream-evidence could one have of Winnicott's view that 'There is no such thing as a baby': i.e. there must be a 'mother and baby', and what better evidence for Fairbairn's view that the basic psychic reality is the 'personal object relation'? What gave me strength in my deep unconscious to face again that basic trauma? It must have been because Winnicott was not, and could not be, dead for me, nor certainly for many others. I have never felt that my father was dead, but in a deep way alive in me, enabling me to resist mother's later active paralyzing inhibiting influence. Now Winnicott had come into living relation with precisely that earlier lost part of me that fell ill because mother failed me. He has taken her place and made it possible and safe to remember her in an actual dream-reliving of her paralyzing schizoid aloofness. Slowly that became a firm conviction growing in me, and I recovered from the volcanic upheaval of that autonomously regressing compelling dream-series, feeling that I had at last reaped the gains I had sought in analysis over some twenty years. After all the detailed memories, dreams, symptoms of traumatic events, people and specific emotional tensions had been worked through, one thing remained: the quality of the over-all atmosphere of the personal relations that made up our family life in those first seven years. it lingers as a mood of sadness for my mother who was so damaged in childhood that she could neither be, nor enable me to be, our 'true selves'. I cannot have a different set of memories. But that is offset by my discovery in analysis of how deeply my father became a secure mental possession in me, supporting my struggle to find and be my 'true self', and by Fairbairn's resolving my negative transference of my dominating mother on to him, till he became another good father who had faith in me, and finally by Winnicott entering into the emptiness left by my non-relating mother, so that I could experience the security of being my self. I must add that without my wife's understanding and support, I could not have had those analyses or reached this result. What is psychoanalytic psychotherapy? It is, as I see it, the provision of a reliable and understanding human relationship of a kind that makes contact with the deeply repressed traumatized child in a way that enables one to become steadily more able to live, in the security of a new real relationship, with the traumatic legacy of the earliest formative years, as it seeps through or erupts into consciousness.
    Psychoanalytic therapy is not like a 'technique' of the experimental sciences, an objective 'thing-in-itself' working automatically. It is a process of interaction, a function of two variables, the personalities of two people working together towards free spontaneous growth. The analyst grows as well as the analysand. There must be something wrong if an analyst is static when he deals with such dynamic personal experiences. For me, Fairbairn built as a person on what my father did for me, and as an analyst enabled me to discover in great detail how my battles for independence of mother from three and a half to seven years had grown into my personality make-up. Without that I could have deteriorated in old age into as awkward a person as my mother. Winnicott, a totally different type of personality, understood and filled the emptiness my mother left in the first three and a half years. I needed them both and had the supreme good fortune to find both. Their very differences have been a stimulus to different sides of my make-up. Fairbairn's ideas were 'exact logical concepts' which clarified issues. Winnicott's ideas were 'imaginative hypotheses' that challenged one to explore further. As examples, compare Fairbairn's concepts of the libidinal, anti-libidinal and central egos as a theory of endopsychic structure, with Winnicott's 'true and false selves' as intuitive insights into the confused psychic reality of actual persons. Perhaps no single analyst can do all that an analysand needs, and we must be content to let patients make as much use of us as they can. We dare not pose as omniscient and omnipotent because we have a theory. Also Fairbairn once said: 'You get out of analysis what you put into it', and I think that is true for both analyst and analysand. I would think that the development of clear conscious insight represents having taken full possession of the gains already made emotionally, putting one in a position to risk further emotional strains to make more emotional growth. It represents not just conscious understanding but a strengthening of the inner core of 'selfhood' and capacity for 'relating'. So far as psychopathological material is concerned, dreaming expresses our endopsychic structure. It is a way of experiencing on the fringes of consciousness, our internalized conflicts, our memories of struggles originally in our outer world and then as memories and fantasies of conflicts that have become our inner reality, to keep 'object relations ' alive, even if only 'bad-object relations', because we need them to retain possession of our 'ego'. It was my experience that the deeper that final spate of dreams delved into my unconscious, the more dreaming slowly faded out and was replaced by 'waking up in a mood'. I found I was not fantasying or thinking but simply feeling, consciously in the grip of a state of mind that I began to realize I had been in consciously long ago, and had been in unconsciously deep down ever since: a dull mechanical lifeless mood, no interest in anything, silent, shut in to myself, going through routine motions with a sense of loss of all meaning in existence. I experienced this for a number of consecutive mornings till I began to find that it was fading out into a normal interest in life: which after all seems to be what one would expect.
    There is a natural order peculiar to each individual and determined by his history, in which (1) problems can become conscious and (2) interpretations can be relevant and mutative. We cannot decide that but only watch the course of the individual's development. Finally, on the difficult question of the sources of theory, it seems that our theory must be rooted in our psychopathology. That was implied in Freud's courageous self-analysis at a time when all was obscure. The idea that we could think out a theory of the structure and functioning of the personality without its having any relation to the structure and functioning of our own personality, should be a self-evident impossibility. If our theory is too rigid, it is likely to conceptualize our ego defenses. If it is flexible and progressive it is possible for it to conceptualize our ongoing growth processes, and throw light on others' problems and on therapeutic possibilities. Balint's 'basic fault' and Winnicott's 'incommunicado core', since they regard these phenomena as universal, must be their ways of 'intuitively sensing' their own basic reality, and therefore other people's. By contrast with Fairbairn's exactly intellectually defined theoretical constructs which state logically progressive developments in existing theory, they open the way to profounder exploration of the infancy period, where, whatever a baby's genetic endowment, the mother's ability or failure to 'relate' is the sine qua non of psychic health for the infant. To find a good parent at the start is the basis of psychic health. In its lack, to find a genuine 'good object' in one's analyst is both a transference experience and a real life experience. In analysis as in real life, all relationships have a subtly dual nature. All through life we take into ourselves both good and bad figures which either strengthen or disturb us, and it is the same in psychoanalytic therapy: it is the meeting and interacting of two real people in all its complex possibilities.

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